1 OPEN STYLE LAB, 2018 Midi-Rox!
Midi-Rox: A reversible wrap dress to empower one-handed dressing
Ray LC (Luo), Michael Tranquilli, Alyssa Wardrop Parsons School of Design: Open Style Lab
Abstract: Disability prevalence and the need for assistance increases with age. Rising trends in the global aging population will multiply the number of the people impacted by disability. The lack of adequate accessible apparel for persons with disabilities (PWD) exacerbates disablement and barriers to community participation (1). In fellowship with Open Style Lab, an interdisciplinary team researched materials, technologies, and design solutions that enhance accessibility to functional clothing for PWD. Our client-centered design originated in collaboration with a person disabled in the activity of dressing due to hemiplegia caused by a Stroke. A closure-less garment design and compensatory dressing strategy were developed to minimize caregiver assistance for persons limited to one-handed dressing. The Midi-Rox dress and Hemi-Wrap method promote safety and modified independence.
Keywords: open style lab, one-handed dressing, stroke, midi-rox, hemi-wrap, occupational therapy, accessible design, adaptive clothing, aging and disability.
User & User Scenario Roxinne is a 70 year old African-American female of her body. Roxinne became disabled to complete and retired Psychologist. She worked at the NY State activities of daily living (ADL) such as dressing, Department of Health for over 25 years. She enjoyed bathing or feeding without assistance from a teaching Psychology courses and speaking at caregiver, disrupting her personal and social lifestyle. motivational and religious events. Her past medical According to the Modified Rankin Scale for history includes Cerebrovascular Accident (CVA), or measuring the degree of disability or dependence in Stroke, and Hypertension (HTN). A stroke occurs the daily activities of people who experience a stroke, when brain cells die from lack of oxygen, usually Roxinne has a level 4 (out of 5) moderately severe caused by a blocked artery or ruptured blood vessel. disability. She currently resides in the long term care When brain cells die, normal functions controlled by community at Riverside Premier Rehabilitation & that region of the brain become impaired. Stroke is Healing Center, in Manhattan, NY. the leading cause of long term disability in the United States and one of the leading causes of disability Design Requests worldwide (2). Hypertension (HTN) is a medical Roxinne, or Roxie, was dissatisfied to wear what she condition in which blood pressure in the arteries is identified as “plain & oversized clothing typically constantly elevated. HTN, or high blood pressure, is worn by disabled people,” since they did not reflect the single most important risk factor for stroke, her personality or professionalism. She requested a according to the American Heart Association (3). mid-length dress with vibrant colors for attending social occasions. Stating, “nothing raises my blood For Roxinne, the stroke impaired regions of her brain pressure more than waiting for someone to help me responsible for math & scientific analysis, get dressed,” she emphasized a goal to reduce her task-specific sequencing, and memory skills, which dependence on caregiver assistance when dressing. made it impractical to resume her career. The stroke She also suggested a design with minimal closures, also caused hemiplegia, or paralysis, on the right side or closures easily manipulated with one hand.
2 OPEN STYLE LAB, 2018 Midi-Rox!
DESIGN ELEMENTS I. Reduce caregiver assistance clothing such as a sweatshirt or jacket. We theorized that putting on a dress like a sweatshirt, using the Roxie has difficulty standing and maintaining her Overhead method, required either significant trunk balance due to paralysis in her right arm, leg and and pelvic shifting, some degree of standing, and/or trunk musculature. She requires 75% assistance bimanual manipulation of the dress past the waistline, from caregivers to stand from, pivot towards, and be and was therefore excluded from our initial design seated onto another surface, as when moving to and consideration. In contrast, a jacket can be put on from her bed and wheelchair. Unable to safely (donned) or taken off (doffed) while seated. support her balance and simultaneously manipulate Accordingly, our first prototype was predicated on clothing, Roxie and her caregivers prefer she mostly utilizing the Over-the-Shoulder method of dress and undress while seated in her wheelchair to compensatory upper body dressing to eliminate the reduce the risk of falling or injury to either party. In need for standing and risk of falling or injury. The 2016, healthcare providers had the highest reported Over-the-Shoulder method entails using the non— cases of non-fatal occupational injuries according to paralyzed arm to guide a jacket sleeve over the the Bureau of Labor Statistics most recent Survey of paralyzed arm and shoulder first. Holding the neck Occupational Injuries and Illnesses (4). Data collar, the jacket is then guided around the backside collected from the Upper/Lower Body Dressing before placing the non-paralyzed arm through the components of the Functional Independence Measure armhole and sleeve. (FIM) indicated that caregivers perform between
75-100% of the components required to fully clothe After seated and standing body measurements were and undress Roxie, in order to save time, promote taken, our designer created a mid-length, jacket-style safety, and conserve energy. These performance and prototype in muslin, a plain-woven cotton fabric to safety considerations were assimilated into our initiate testing with Roxie. We envisioned the design by proposing strategies that would allow one- dressing process to begin with caregivers placing the handed dressing and undressing to be completed from dress within the wheelchair, neck collar draped over a seated position. the backrest and the sleeves draped over the armrests of her wheelchair. With the outside of the dress Individuals with upper extremity impairments are facing down, Roxie could sit atop her dress within the trained by occupational therapists in rehabilitative wheelchair and begin one-handed dressing (See and/or compensatory strategies to resume functional figure A). She need only guide her arms through the activity. Rehabilitative strategies aim to restore lost sleeves before overlapping the front panels to functioning while compensatory strategies aim to complete dressing. In this manner, caregivers would adapt procedures, devices and environments to have the convenience to set out the dress in advance. resume participation in activities of daily living. Positioning the dress behind and underneath Roxine Although rehabilitative strategies to restore lost would also eliminate the need for assistance to function were reinforced over the 10-week design maneuver the dress around her backside, effectively process, our mission was to investigate adaptive removing one step of the Over-the-Shoulder method. strategies to improve performance in the activity of dressing. Since Roxie is unable to step into or pull up clothing due to impaired balance and use of her right arm, we disregarded compensatory strategies that began the dressing process from the lower body. The Overhead and Over-the-Shoulder methods are two compensatory strategies for dressing upper body Figure A.
3 OPEN STYLE LAB, 2018 Midi-Rox!
Following a stroke, individuals with hemiplegia are such as reaching and grasping clothes, or taught by occupational therapists that impaired manipulating closures like zippers, snaps, buttons, extremities get dressed first, and undressed last. This knots or belts. Upper Arm Function and Hand one-handed work simplification and energy Movement scores in the left extremity revealed conservation strategy is akin to executing the most within functional limits (WFL) strength, difficult components of a task first. Admittedly, coordination, and range of motion (ROM), indicating Roxie had difficulty recalling this vital dressing all dressing and closures would be completed solely strategy previously learned in rehabilitation. In error, using the left arm and hand. In order to reduce the she would repeatedly attempt to dress her left side gross and fine motor coordination constraints of first, resulting in more time, effort and assistance to bimanual closures, our team speculated that opposing complete dressing. magnets would be the most simplified manner to fasten/unfasten a dress since general approximation After constructing and testing our initial prototype, would result in opposing magnets connecting. further data collected from the Nottingham Stroke Dressing Assessment (NSDA), along with video We surmised that frontal overlapping panels would analysis, revealed that Roxie had improved best facilitate one-handed dressing by minimizing performance using the Overhead method compared the range of movement required to connect the to the Over-the-Shoulder method of dressing her magnets, and by maintaining all closures within upper body. Specifically, reduced time, effort, and sight. Magnet locations were determined according assistance were recorded. Over numerous trials, it to comfort and fit while in a seated position. Three became evident that donning a shirt by first placing (3) magnets, each 0.75 inch in diameter, were the neck collar overhead was a more intuitive enclosed in a thin plastic casing. The magnet casings behavior for Roxie to initiate, as opposed to dressing were diagonally sewn atop the inner panel of fabric her impaired side first. She also displayed significant from the left shoulder, to the right chest, and at the ease when locating the neck collar of a shirt right side torso locations (See Figure B). Opposing compared to the armhole in the sleeve. Placing the magnets were sewn at corresponding locations on the garment overhead first created a draping of the fabric inside of the outer, overlapping panel of fabric. that naturally expanded the armhole. This sequence provided a static target location which required less effort to approximate and guide her arm through the sleeve. Surprisingly, after the garment was overhead, Roxie exhibited a tendency to correctly dress her impaired side first. These results appeared to nullify our initial design hypothesis of utilizing an Over-the-Shoulder method of one-handed dressing to reduce the need for standing and caregiver assistance.
II. Minimal closures to manipulate Figure B. Most closures are designed for bimanual manipulation and present reduced functionality for After the prototype was over her shoulders with arms users limited to one -handed dressing. Evidenced by through the sleeves, Roxie demonstrated considerable low scores in Upper Arm Function and Hand ease overlapping the panels and connecting the Movement sections of the Motor Assessment Scale, individual magnets using her left hand. However, the Roxie is unable to use her right arm or hand to disadvantage of using magnetic closures on our perform gross and fine motor coordination tasks design became apparent before this final step.
4 OPEN STYLE LAB, 2018 Midi-Rox!
Prior to dressing, as the dress was being placed precursory steps when using the Over-the-Shoulder within the wheelchair, the magnetic closures method of dressing. In contrast, when using the consistently attached to the metallic frame of the Overhead method, she displayed improved wheelchair. This obstacle imposed more time and performance dressing her upper body by first placing effort to detach the magnets and correctly reposition the neck collar overhead, like a sweatshirt, before the dress, often requiring numerous attempts. guiding her arms through the sleeves. Accordingly, Regardless of these efforts, after sitting atop her we replaced the Over-the-Shoulder method of first dress, the magnets frequently reattached to other guiding the sleeve over the impaired extremity with metallic locations on the wheelchair. Attempting to the Overhead method of guiding the neck collar locate and detach the magnets as a precursor to overhead first. By modifying and combining dressing became discouraging for all parties elements of both the Over-the-Shoulder and involved. Despite the simplicity and success Roxie Overhead methods, we invented and fabricated a new demonstrated using this magnetic closure design to clothing pattern, the Midi-Rox (See Figure C). complete the dressing process, the preliminary steps of detaching magnets, positioning arm holes, and donning sleeves over the arms and shoulders still required assistance from caregivers. These results appeared to nullify another preliminary design hypothesis suggesting that frontal overlapping magnetic closures would minimize the dexterity constraints for one-handed dressing.
Intuitive Design Solutions Committed to providing Roxie with an accessible solution that reduced her dependence on caregiver assistance for dressing, we re-evaluated the strengths Figure C. and weaknesses of our previous designs and Roxie’s functional performance. Convinced that modifying Most notably, our pattern was atypically fashioned those designs and procedures would accommodate with two (2) neck collars on opposing sides. This shortcomings, another prototype was developed to unconventional attribute was the stepforward to further assimilate these elements. eliminating magnetic and all closures on the dress. Building on the Midi-Rox pattern, we further We could not overlook the safety risks for both developed an innovative, one-handed compensatory Roxie and her caregivers when standing to dress and dressing method, the Hemi-Wrap (See Figure D). chose to maintain the fall prevention strategy of In conjunction with the Midi-Rox dress pattern, the dressing from a seated position. Extracting this Hemi-Wrap method of dressing and undressing was modified component from the Over-the-Shoulder specifically designed to enhance Roxie’s functional method affirmed that caregivers would still set up the abilities by accommodating her intuitive dressing dress for Roxie to sit atop. However, to allow for behavior. convenient placement within the wheelchair, all magnetic closures would be removed from this prototype. Although Roxie was successful in manipulating the magnets to fasten and unfasten her dress, she continued having difficulty with the
5 OPEN STYLE LAB, 2018 Midi-Rox!
and sleeve. Somewhat imperceptible to Roxinne, she had just completed the vital therapeutic strategy of dressing the impaired extremity first. Repeating this 3-step sequence to now dress her left side, Roxie grasped the neck collar positioned on the right armrest and placed the second neck collar over her head.
Figure D. Without difficulty, she was able to guide her non- paralyzed left extremity through the draping armhole Our designer constructed a prototype from our new and sleeve to complete the dressing process. Directing technical pattern in a jersey knit fabric. Although this the neck collar and sleeve from one side of the soft fabric was excellent for replicating a flowing wheelchair to dress the opposite side of the body dress, it would knowingly become overstretched after produced a frontal, overlapping wrap-style dress. a few trials. We only required the perspective to After eight (8) trials Roxie could properly sequence validate or refute the Midi-Rox pattern and the Hemi-Wrap method of dressing with only verbal Hemi-Wrap method were practical solutions to instruction, significantly reducing the amount of functional clothing. Prior to, and during trials, Roxie assistance required to dress herself. was instructed in the Hemi-Wrap dressing method using verbal directions, visual demonstrations, and Following each dressing trial, Roxie was instructed in hand-over-hand sequencing to facilitate carryover. the Hemi-Wrap undressing method using verbal We began trials by positioning the dress within the directions, visual demonstrations, and wheelchair, outside facing down, and the sleeves hand-over-hand sequencing to facilitate carryover. draped over the arm rests. However, the Midi-Rox This method entailed grasping and removing the last closure-less pattern emphasized the bilateral neck neck collar placed overhead before withdrawing the collars being placed over the front end of each arm left arm from the sleeve. Identical in process, Roxie rest for easy location and acquisition (See Figure E). then grasped and removed the first neck collar placed overhead before assisting the withdrawal of her impaired right extremity from the sleeve. Appropriately, the Hemi-Wrap method also reinforces the therapeutic strategy to undress the impaired extremity last. Furthermore, Roxie was independently able to reposition the neck collars over their corresponding armrests on her wheelchair, essentially positioning the dress to be donned again. After six (6) trials, Roxie could independently sequence the Hemi-Wrap method to undress herself.
Figure E. III. A vibrant dress for social occasions
Before constructing a mid-length dress for Roxine After sitting atop her pre-positioned dress, Roxie (Midi-Rox), our designer researched fabric qualities began the Hemi-Wrap method of one-handed dressing. Using her left hand to grasp the neck collar that prioritized function into the design. By utilizing high-stretch fabric, we were able to expand the error located on the left armrest, she instinctively placed tolerance when donning and doffing the neck collars the neck collar over her head. With assistance from and sleeves. This feature would also accommodate her free left hand, Roxie effectively positioned and changes in body size or posture over time and easily guided her right arm through the draping armhole contour around any undergarment.
6 OPEN STYLE LAB, 2018 Midi-Rox!
Since Roxie is seated throughout most of the day, Our designer cut and crafted the Midi-Rox dress choosing a breathable material with superior according to the technical pattern and Roxie’s body moisture-wicking qualities was essential for personal measurements to achieve a custom tailored fit. comfort and hygiene. It was equally important to utilize material with easy care instructions to minimize time and cost of cleaning. After reviewing numerous material characteristics, we selected the Polartec® Power Grid™ double-sided knit jersey (See Figure F). Inclusive of the aforementioned elements, this material has a slight melange weave on one side and grid texture on the opposite which provides variation of style for different occasions.
Technology Considerations In the chronic stroke population, balance impairment Figure F. and fall risk are associated with lower quality of life (QOL) scores (6). Individuals with hemiplegia often Practically symmetrical by design, the Midi-Rox have difficulty maintaining postural control and closure-less dress is also reversible, allowing Roxie balance due to weakness in the trunk, arm, and leg the benefit of two dresses from one garment. Dress, musculature. In an effort to help Roxie identify and because it may be seen in social encounters before correct her postural imbalance when sitting or conversation can be initiated, has a certain priority standing, we investigated technological solutions to over discourse in the establishing of identity (5). facilitate awareness and self-corrective behavior. Empowering her desire for self-expressive clothing, Our engineer programmed degrees of limitation for Roxie chose a color combination of Teal on one side postural deviations into an Arduino Metro Mini and Kiwi on the reverse to accentuate her Spring board. Using conductive thread, a light-emitting through Fall wardrobe. The reversible dress required diode (LED) was connected to the mini board. We a flatlock stitch to create flat seams on both sides of proposed attaching the mini board and LED on the dress for preventing skin chafing and irritation. Roxie’s dress to signal when her trunk posture To complement the high stretch fabric, all seams deviated from the pre-set parameters. The blinking were decoratively sewn with a cobalt blue wooly LED would notify Roxie of postural asymmetry and nylon stretch thread. A wide scoop neckline was prompt self-corrective action. Despite the potential incorporated to accommodate Roxie’s long, thick value to identify and correct postural asymmetries, dreadlocks when donning and doffing the neck these technologic aspects were excluded from our collars overhead. A slight vent on the back hemline final design as Roxie was disinterested to incorporate was also added to help caregivers easily center the any “gadgets” into her dress. dress within the wheelchair.
7 OPEN STYLE LAB, 2018 Midi-Rox!
Conclusion The Midi-Rox pattern and Hemi-Wrap method of References one-handed dressing validated our approach to minimizing the restrictions of clothing fasteners and 1. Kabel, Allison. (2016) Disability, the Senses and caregiver assistance. Accommodating intuitive Apparel: Design Considerations. The Senses and Society 11:2, pages 206-210. behaviors through rehabilitation sciences and adaptive design can significantly enhance functional 2. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart performance and safety when dressing. Improving Disease and Stroke Statistics-2017 Update: A accessibility to stylish clothing for persons with Report From the American Heart Association. disabilities can reduce barriers to self-expression Circulation. 2017;135(10):e146-e603. and meaningful participation in society. Further 3. Meschia JF, Bushnell C, Boden-Albala B, et al. research is warranted to determine the effectiveness Guidelines for the primary prevention of stroke: a of the Midi-Rox design and Hemi-Wrap methods as statement for healthcare professionals from the equitable use solutions for non-stroke populations American Heart Association/American Stroke disabled in the activity of dressing. Association. Stroke. 2014;45(12):3754-832.
4. Bureau of Labor Statistics (2017). 2016 Survey of occupational injuries & illnesses charts package. Midi-Rox Team U.S. Department of Labor. Michael Tranquilli, Occupational Therapist https://www.bls.gov/iif/osch0060.pdf.
[email protected] 5. Stone, G. P. (1962). Appearance and the Self. In A. M. Rose (Ed.), Human Behavior and Social Processes: An Interactionist Approach (pp. Alyssa Wardrop, Fashion Designer 86-118). New York: Houghton Mifflin. [email protected] 6. Schmid, AA, Van Puymbroeck, M, Altenburger, Ray LC (Luo), Engineer Neuro-Designer PA, Miller, KK, Combs, SA, and Page, SJ [email protected] (2013). Balance is associated with quality of life in chronic stroke. Top Stroke Rehabil. 20, 340-6. Roxinne Gassette, Psychologist